Breast Surgery New Patient Form
What a breast surgery new patient form asks, with sample questions on referral, imaging, and breast and family history.
A breast surgery new patient form records the referral, past mammograms, breast procedures and treatment, gynecologic history, and family cancer history before a first breast center visit. Breast centers at Vanderbilt, NorthShore University HealthSystem, and UCLA Health use their own versions.
Breast surgery new patient form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a breast surgery new patient form in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample breast surgery new patient form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- Who referred you to see us?Referral
- Who is your primary care physician?Referral
- When was your last mammogram?Imaging
- Do you have regular mammograms?Imaging
- Have you had a breast biopsy before?Breast history
- Have you had breast reduction or augmentation?Breast history
- Have you had chemotherapy or radiation before?Past treatment
- Have you received hormone therapy?Past treatment
- How old were you at your first period?Gynecologic history
- Have you reached menopause, and at what age?Gynecologic history
- Which relatives have had breast cancer?Family history
- Is there ovarian cancer in your family?Family history
These are examples to read, not a form to fill in.
Breast surgery new patient form: FAQ
What does a breast surgery new patient form ask?
The sample questions on this page are based on intake forms from Vanderbilt Breast Center, NorthShore University HealthSystem, and UCLA Health's Santa Monica Breast Center. This page groups them into six areas: referral, imaging, breast history, past treatment, gynecologic history, and family history.
Who fills in a breast surgery new patient form?
The patient, before the first visit. NorthShore's form asks patients to print it and answer every question, writing 'Unknown' where needed.
Does it ask about gynecologic history?
Yes. All three forms ask about age at first period, menopause, pregnancies, and hormone use such as birth control pills or hormone replacement therapy.
Does it ask about family history?
Yes. The forms ask which relatives had breast cancer, and NorthShore and UCLA Health also ask which side of the family and about Ashkenazi Jewish ancestry.
Is there a breast surgery new patient form template?
The sample questions on this page show a typical set drawn from the three breast center forms named above.
What happens after the form is completed?
The breast center team reviews the answers before the visit. Vanderbilt's form has an office-use section for imaging, the exam, and the plan.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
